SOCIAL DETERMINANTS OF ORAL AND GENERAL HEALTH

Wael Sabbah, BDS, DDPH, MSc, PhD

Oregon Health & Science University, School of Dentistry

UCSF, School of Dentistry, San Francisco, April 2012

Outlines

• Oral health and general health: the common risk factors.

• The social determinants: evidence and characteristics (social gradient).

• Pathways for health inequalities: can we explain the social gradient?

• Can behavioral factors account for inequalities?

• The role of psychosocial factors?

• Contribution of health services

• Strategies and policies to address health inequalities.

2

Public health is a social issue.

“Interventions aimed at reducing disease and saving lives succeed only when they take the social determinants of health adequately into account.” (Lancet, 2005)

Dr Lee Jong-Wook(Director General, WHO)

3

“…oral health and general health should not be interpreted as separate entities”Surgeon General’s Report on Oral Health of America, 2000

4

• Direct links between oral health and general health:

1. Specific systemic conditions affect oral health

2. Oral conditions affect general health (inflammatory, nutritional pathways).

Or co-morbidity

5

• General susceptibility: Linked to the commonality of the social determinants.

• There are common, rather than specific, risk factors that affect a wide range of chronic conditions, including oral health.

6

Common Risk Factor

DietObesity

Diabetes

Cancers

Cardiovascular diseases

Dental caries

Periodontal diseases

Skin diseases

Tobacco

Alcohol

Hygiene

Sheiham and Watt 20007

The Determinants of the Common Risk Factors

• ‘Smoking, obesity and heavy drinking are causes of ill-health, but what are the causes of these behaviors?’ WHO CSDH,

Fair Society, Healthy Lives, Marmot (2010). • Choices pertaining to health-related

behaviors are situated within economic, historical, family, cultural and political contexts.

8

The Determinants of the Common Risk Factors

• Individual behaviors such as smoking, diet, alcohol, physical activities, general and oral hygiene, attendance for medical and dental screening and care are largely influenced by the social environments and conditions in which people live and their status.

9

The causes of the causes

Socio-environmental conditions

Economics

Employment

Status

Sex

Tobacco

Diet

Alcohol

Hygiene

Stress

Chronic diseases

Distal riskfactors

Distal riskfactors

Proximal modifiablerisk factors

Proximal modifiablerisk factors OutcomeOutcome

Geoffrey Rose

10

The Determinants of the Common Risk Factors

• Proximal risk factors explain a relatively small portion of the variance in socioeconomic differences in health, thus highlighting the importance of psychosocial, economic, political and environmental factors to health and disease. These factors are known as the social determinants of health.

11

Obesity

Cancers

Heart disease

Respiratory disease

Dental caries

Periodontal diseases

Trauma

Diet

Stress

Control

Hygiene

Risk Factors Diseases Risk Factors

Tobacco

Alcohol

Exercise

Injuries

Common Risk Factor Approach: Including Societal Risk

School

Policy

Workplace

Housing

Political environment

Physicalenvironment

Socialenvironment12

Socioeconomic inequalities in health

Rates of morbidity and mortality are successively lower at successively higher rungs on the social ladder. Those in the higher ranks are healthier than those immediately below them.

This phenomenon is also known as the social gradients.

Marmot , Wilkinson , 2006.

13

Life expectancy by social class

72

74

76

78

80

82

84

Social Class I Social Class II Social Class IIIN Social Class IIIM Social Class IV Social Class V

Lif

e ex

pec

tan

cy

Life expectancy by social class, England and Wales 1992-1996 (Marmot 2003)14

Self-rated health among USA adolescents

Starfield et al 2002 15

16

Life expectancy by neighbourhood income in urban Canada, 1971-2001

Statistics Canada17

Life expectancy differences: USA

Travel from the Southeast of downtown

Washington to Montgomery County Maryland. For

each mile travelled life expectancy rises about a

year and a half.

There is a twenty year gap between poor blacks at

one end of the journey (Male LE 57) and rich whites

at the other (LE 76.7).

Travel from the Southeast of downtown

Washington to Montgomery County Maryland. For

each mile travelled life expectancy rises about a

year and a half.

There is a twenty year gap between poor blacks at

one end of the journey (Male LE 57) and rich whites

at the other (LE 76.7).

Marmot , 2005.

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Life expectancy differences in London

Westminster

Waterloo

Southwark

London Bridge

BermondseyCanada

Water

CanaryWharf

NorthGreenwich

Canning Town

London Underground Jubilee Line

8 stations between Westminster and Canning Town on the Jubilee Line: nearly1 year of shorter lifespan per station (as one travels east)

River Thames

Male life expectancy69.0 (67.3-70.8)

Female life expectancy76.9 (75.3-78.5)

Male life expectancy76.2 (74.3-78.2)

Female life expectancy82.9 (80.5-85.3)

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Oral health inequalities

Significant social class differences – Caries– Periodontal diseases– Oral cancers– Self reported oral health

status

Individual, area and population level

Certain ethnic minority groups and socially excluded groups

Close link with general health

Watt and Sheiham (1999)

20

Education gradients in perceived oral/general health, periodontal disease, and ischemic heart disease.

0

0.5

1

1.5

2

2.5

3

3.5

4

Perceived oralhealth

Perceivedgeneral health

Periodontitis Ischemic heartdisease

Od

ds

Rat

io Education>12 year

Education=12 years

Education<12years

Sabbah et al 2007 21

Social gradients in oral health

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Social Gradients in Oral Health Many studies have shown a social gradient

in oral health Almost all have been carried out on adults1-

9

Only a couple on adolescents10-11

They have mostly used 1 or 2 socioeconomic position markers (not always the same)

1. Drury TF, Garcia I, Adesanya M (1999). Ann N Y Acad Sci; 896:322-324.2. Sanders AE, Slade GD, Turrell G, John SA, Marcenes W (2006). Community Dent Oral Epidemiol; 34: 310-319.3. Do LG, Roberts-Thomson KF (2007). Aust Dent J;52:249-251. 4. Morita I, Nakagaki H, Yoshii S et al. (2007) . Eur J Oral Sci; 115: 275-279.5. Sabbah W, Tsakos G, Chandola T, Sheiham A, Watt RG (2007). J Dent Res; 86: 992-996.6. Holst D (2008). Community Dent Oral Epidemiol; 36: 326-334.7. Sanders AE, Slade GD, John MT et al. (2009). J Epidemiol Community Health; 63: 569-574. 8. Tsakos G, Sheiham A, Iliffe S et al. (2009). Eur J Oral Sci; 117: 286-292.9. Finlayson TL, Williams DR, Siefert K, Jackson JS, Nowjack-Raymer R (2010). Am J Public Health; 100 (Suppl.1):S246-

S255.10. Thomson WM, Poulton R, Milne BJ, Caspi A, Broughton JR, Ayers KM (2004). Community Dent Oral Epidemiol; 32:345-

353.11. Lopez R, Fernandez O, Baelum V (2006). Community Dent Oral Epidemiol; 34: 184-196.

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Morris, Steele, White. 2001

Loss of periodontal attachment and social class

24

Prevalence of oral morbidity according to relative social status and absolute material resource

Sanders et al. 200625

26

Income inequality and periodontal disease

Sabbah et al 2010 27

Social determinants of health

• What are the pathways?

28

Environment and

socioeconomic position

Psychosocial factors

Health-related behaviors

Oral Health

Simplified pathways between the social determinants and oral health

Gender, age, ethnicity

Health Services

Life course

29

The role of health-related behaviors

Health behaviors are social grade specific.“Poor people behave poorly”

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People who are in the lower social grades are more likely to engage in a wide range of risk related behaviors and less likely to be involved in health promoting ones.

Health behaviors are socially patterned

Lynch, Kaplan, Salonen Why do poor people behave poorly? Variation in adult health behaviours and psychosocial characteristics by stages of the socio-economic life course. Soc Sci Med 1997; 44: 809-819.

31

Smoking and drinking in Scotland 2003

MacIntyre S 2008

32

Health behaviors by education

The Norwegian Institute of Public Health33

Health Survey for England, 2001

Behavioral factors: diet

34

Probabilities of engaging in a cluster of health compromising behaviors

highest middle lowest highest 2nd highest 2nd lowest lowestEducation Income

0.9

0.95

1

1.05

1.1

1.15

1.2

1.25

1.3

1.35

1.4

Unpublished data (NHANES)35

0

0.5

1

1.5

2

2.5

Education = 12 yrs Education < 12 yrs

Od

ds rati

o fo

r p

erc

eiv

ed

po

or o

ral h

ealt

h

adjusted for confounders

adjusted also for behaviours

Do health behaviors “explain” health inequalities?

Sabbah, Tsakos, Sheiham, Watt (2009). Soc Sci Med; 68(2): 298-303.

US adults (NHANES III)

36

0

0.5

1

1.5

2

2.5

Education = 12 yrs Education <12 yrs

Co

un

t ra

tio

of to

oth

su

rface

loss

adjusted for confounders

adjusted also for behaviours

Sabbah, Tsakos, Sheiham, Watt (2009). Soc Sci Med; 68(2): 298-303.

US adults (NHANES III)

Do health behaviors “explain” health inequalities?

37

Evaluating the role of dental behavior in oral health inequalities

“To reduce social inequalities in adult oral health, efforts need to be directed to factors other than the dental behaviors of individuals…. Rather than focusing on individuals alone, the approach needs to achieve a better balance of targeting both individual level factors and also the social environments in which health behaviors of individuals are developed and sustained.”

Sanders, Spencer & Slade (2006)

38

Stress and the health

• Stress induced by SEP, work and living environment affects health.

• Stress affects health indirectly via health-related behaviors,

or directly through biological changes:When the external and internal stress challenges are chronic and frequently beyond the normal ranges of adaptive responses, “wear and tear” on regulatory systems occurs and allostatic load accumulates. (McEwen, 1998)

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Stress and the health

Stressful situation which affect general health (cardiovascular disease) and oral health (periodontal disease):

Work related mental demand,

lack of control at work and/or at home,

unemployment,

negative life events,

low levels of marital quality(Marmot and Wilkinson, 2006; Seeman et al 2001; Sheiham and Nicolau, 2005).

40

Probabilities of having ischaemic heart disease and periodontal disease by increased levels of allostatic load

0

0.5

1

1.5

2

2.5

3

Ischaemic HeartDisease

Gingival Bleeding Loss of PeriodontalAttachment

Pocket Depth

Sabbah et al 200841

Change in education gradients in ischaemic heart disease and periodontitis after adjusting for allostasis

0

0.5

1

1.5

2

2.5

education=12years education<12years education=12years education<12years

Ischaemic heart disease Periodontitis

Od

ds

Rat

io

unadjusted for allostasis

adjusted for allostasis

Sabbah et al 200842

Stress and Health-Related Behaviors

• Higher levels of biological markers of stress were associated with higher probabilities of engaging in a number of oral and general health-compromising behaviors after accounting for demographic and socioeconomic factors.

Sabbah 2011, unpublished data

43

0.98

1

1.02

1.04

1.06

1.08

1.1

1.12

1.14

1.16

1.18

1.2

Less f requent exercise Fattening food Fewer f ruits and vegerables

Adjusted odds for poor health-related behaviors for an extra marker of allostatic load

44

1.04

1.06

1.08

1.1

1.12

1.14

1.16

1.18

1.2

1.22

1.24

Smoking Less f requent dental visits Oral hygiene

Adjusted odds ratios for poor health-related behavior for an extra marker of allostatic load

45

Health Services

Recommendations for Actions for Universal Health Care (WHO Commission on Social Determinants of

Health, 2009).Universal coverage of quality services,

focusing on Primary Health Care.Tax/ insurance-based funding, ensuring

universal coverage regardless of ability to pay

46

47

48

0

5

10

15

20

25

30

35

40

45

Per

cen

t

Population health in England and US (Banks et al 2006)

England

US

49

Universal health coverage and health disparities (USA/ Canada)

Poorest Richest0

5

10

15

20

25

30

35

Self-rated general health (poor/fair) by household income

Canada

US

per

cen

tag

e

Poorest Richest0

5

10

15

20

25

Severe mobility limitation by household income

Canada

US

per

cen

tag

e

50

<1 year 1 to<3years 3years+/ never0

10

20

30

40

50

60

70

Dental Visits Canada and USA

Canada

US

Last dental visit

per

cen

tag

e

All Insured UninsuredCanada US

20

30

40

50

60

70

80

90

Percentage with regular medical doctor

per

cen

tag

e

Use of medical and dental care (USA/ Canada)

51

Exclusion of dental services from the universal health coverage (in Canada)

• “All people visit physicians. Young, healthy, wealthy, well educated people visit dentists”.

• Sabbah W, Leake JL. Comparing characteristics of Canadians who visited dentists and physicians during 1993/94: A secondary analysis. JCDA, 2000, 66 (2): 90

Visits to Dentist and Family Physician, by Income

0102030405060708090

< 20,000 20,000-49,999

>49,000

Income ($)

% o

f Peo

ple R

epor

ting

1≥ V

isits

%visits dental

%visits physician

52

Early life course

• Biological, behavioral and social hazards operate across the life course and influence the development of chronic diseases.

• Tracking the progress of general and oral conditions through the life course.

53

Priorities for research

• Social determinants of health.• Commonality of the social and behavioral

risk factors for oral and general health.• Associations between oral and general

health.

54

Priorities for research

• Oral and general health of ethnic minorities and indigenous populations.

• Inequality in the use of health services.• Life course approach to investigate the

progress of risk factors, and tracking of chronic conditions.

55

Fiscal Measures

National &/or local policy initiatives

Legislation/Regulation

Healthy Settings- HPS

Community Development

Training other professional groups

Media Campaigns

School dental health education

Chair side dental health education

Clinical Prevention

‘Upstream’

Healthy Public Policy

‘Downstream’

Health Education & Clinical Prevention

Upstream - downstream interventions

56

Policy implications

• Incorporate research findings on the social determinants in health promotion intervention.

• Research on oral health should be incorporated as appropriate into policies for the integrated prevention and treatment of acute and chronic diseases into health policies.

• We should explore how to combine forces and use our abilities to change environmental, cultural, and individual factors through joint effort.

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